VP, Medicaid Clinical Operations

Role Overview

• Lead Medicaid Clinical Operations, including clinical and nonclinical teams supporting utilization management, care management/service coordination, program operations, process improvement, training, and project execution.
• Establish clear operating rhythms, accountability structures, workforce productivity expectations, and performance management processes across distributed clinical operations teams.
• Build and sustain an engaged, high-performing leadership culture focused on associate development, retention, operational discipline, and measurable outcomes.
• Develop and execute Medicaid clinical operations strategies that support growth, market expansion, state contract requirements, enterprise priorities, and scalable operating model transformation.
• Translate clinical strategy, market commitments, and program designs into operational workflows, staffing models, performance targets, and implementation plans.
• Oversee Medicaid utilization management and care management/service coordination functions, ensuring consistent clinical practices, regulatory compliance, timely decision-making, and appropriate escalation management.
• Strengthen care navigation, member access, provider coordination, and interventions that reduce avoidable utilization and improve health outcomes.
• Partner with Product, Technology, Data, Analytics, and Operations teams to translate Clinical Operation’s needs, regulatory requirements, workflow gaps, and performance priorities into clear business requirements, use cases, and solution expectations.
• Establish, monitor, and improve key performance metrics, including quality, compliance, cost of care, access, utilization, productivity, service levels, member experience, provider experience, revenue, margin, and client or contract performance commitments.

Requirements

• Bachelor’s degree required; advanced degree in nursing, public health, healthcare administration, business administration, social work, or a related field preferred.
• Strongly preferred Clinical license, nursing degree, or other healthcare credential; MD is not required.
• 10 plus years of progressive experience in Medicaid, managed care, clinical operations, utilization management, care management, population health, health services operations, or healthcare transformation.
• 5 plus years leading large, distributed clinical and/or operational teams, including leaders of leaders, through scale, change, and performance improvement.
• Deep understanding of Medicaid programs, state contract requirements, regulatory expectations, integrated care models, LTSS, behavioral health, complex populations, and DSNP coordination.
• Demonstrated ability to translate strategy into operational execution, standardized workflows, measurable outcomes, and sustainable performance improvement.
• Experience partnering with Product, Technology, Data, and Analytics teams to translate clinical operations needs into business requirements, workflow priorities, reporting needs, user adoption considerations, and measurable solution outcomes preferred.
• Strong financial acumen, including experience managing budgets, staffing models, productivity, labor efficiency, revenue, margin, and operating performance.
• Proven ability to lead through ambiguity, influence cross-functionally, manage risk, engage senior stakeholders, and communicate effectively with executive audiences.

Benefits

• Health insurance
• 401(k) retirement plans
• Paid time off
• Flexible work arrangements
• Professional development opportunities